Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SSA-4640 Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare) (As completed by the claimant.)	Form	Modified	Available
Form SSA-4640 Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the finanical institution.)	Form	New	Available
Supporting Statement 0729.doc	Supporting Statement A	Uploaded 2009-06-17	Available
addendum.doc	Supplementary Document	Uploaded 2009-05-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
43717	Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare) (As completed by the claimant.)	Form	Modified
189623	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the finanical institution.)	Form	New

ICR Details

OMB Control No: 0960-0729	ICR Reference No: 200902-0960-009
Status: Historical Active	Previous ICR Reference No: 200606-0960-007
Agency/Subagency: SSA	Agency Tracking No:
Title: Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare Part D Subsidy)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/10/2009
	Date Received in OIRA: 06/17/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2012	36 Months From Approved	11/30/2009
Responses	10,000	0	20,000
Time Burden (Hours)	416	0	834
Cost Burden (Dollars)	0	0	0

---

Abstract: Individuals who apply for the Medicare Part D subsidy must report all of their financial accounts. In cases where SSA chooses to verify applicants' account balances, Form SSA-4640 will be used: 1) to obtain applicants' authorizations to contact their financial institutions and 2) to verify balances with the financial institutions. The respondents are applicants for the Medicare Part D subsidy with financial accounts and the institutions where those accounts are held.

---

Authorizing Statute(s): PL: Pub.L. 108 - 173 101 Name of Law: Medicare Prescription Drug Benefit
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 7506	02/17/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 18782	04/24/2009
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the finanical institution.)	SSA-4640	Authorization...
Authorization for SSA to Obtain Account Records From a Financial Institution and Request for Records (Medicare) (As completed by the claimant.)	SSA-4640	Authorization for the Social Security Administration to Obtain Account Records from a Financial Institution and Request for Records (Medicare) (As completed by the claimant)

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	10,000	20,000	0	0	-10,000	0
Annual Time Burden (Hours)	416	834	0	0	-418	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The public reporting burden decreased from 834 hours to 416 hours. The decrease is due to a reduction in the number of respondents from 20,000 to 10,000, since most beneficiaries applied at the beginning of the Medicare Part D program’s Application for Help with Medicare Prescription Drug Plan Costs initiative. Further, prior to ROCIS we could not show the separate breakdown of respondents. Although there is only one form, there are two different groups of respondents (claimants and financial institutions) completing the same form.

---

Annual Cost to Federal Government: $2,200

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/17/2009

---